PERSONAL HISTORY
Date: ______Cell Phone: ______
Patient:( Last Name/: ______
: (First Name/) ______
Street Address: ______
City:______State: ______Zip: ______
Sex: □ M □ F Age:______Birthdate:______
How do you find this clinic? □ by newspaper
□ by Internet □ magazine □ by friend______
Social Security#:______- ____ - ______Driver’s License#: ______
Insured’s Name(Last Name) ______(First Name): ______
Relationship to Insured: □Self/ □Spouse / □Child/ □Other:______
Condition Related to □Illness/ □Employment/ □Auto/ □Other:______
EMPLOYER / Company Name:______Occupation:______Address:______
City:______State:______Zip:______Phone:______
CURRENT HEALTH CONDITION
Major Complaint:
1: ______
2: ______
3: ______
4: ______
When did this Condition begin:______
Are there others in your family with this same condition: ______
Other Therapists Seen for This Condition:□No / □Yes:______
If disables from work please give dates:______
□ Job Related□ Auto Related Date of Accident or Injury:______
Medication: □Nerve Pills □Muscle relaxers□Insulin
□Blood Pressure □Aspirin/Similar □Other:______
PAST HEALTH HISTORY
PLEASE CHECK OR DESCRIBE
Major surgery/ Operations□Appendix/ □Tonsils/ □Gall bladder
□Hernia□Heart□Back□Neck( □Leg/ □Other:______
Major Accidents or Falls:______
Hospitalization:□No / □Yes:______
Previous Physical Therapy Care □No / □Yes:______
Have you been treated for any health condition in the last year? □No / □Yes:______
Does anyone else in your family have the same or similar condition?□No / □Yes:______
Below are lists of diseases which may see unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of chiropractic care.
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Check any of the following Diseases you have had:
□Pneumonia□Mumps□Influenza□Rheumatic Fever
□Small Pox □Pleurisy □Polio □Chicken Pox
□Arthritis □Tuberculosis □Diabetes □Epilepsy □Cancer
□Whooping □Mental Disorder □Anemia □Heart Disease
□Measles □Thyroid □Eczema
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Check any of the following things you have:
□Coffee □Tea □Alcohol □Cigarettes □White Sugar------
Check any of the following you have had the past
☞☞☞ MUSCULO-SKELETAL CODE
□Low back pain □Neck pain □Pain between shoulders □Arm pain
□Joint pain/Stiffness □Walking problems □General stiffness
□Gas/Bloating after meals □Heartburn □Black/Bloody stool
□Difficult chewing/Clicking jaw□Colitis
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☞☞☞ GENITO-URINARY CODE
□Bladder Trouble□Painful/Excessive Urination□Discolored Urine
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☞☞☞ FEMALES ONLY:
When was your last period?______
Are you Pregnant? □Yes □No □Not sure
☞☞☞ NERVOUS SYSTEM CODE)
□Nervous □Numbness □Paralysis □Dizziness
□forgetfulness □Confusion/Depression □Fainting
□Convulsions□Cold(/Tingling Extremities □Stress
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Check any of the following you have had the past
☞☞☞ C-V-R CODE
□Chest pain □Short breath □Blood pressure problems
□Irregular heartbeat □Lung problems/Congestion
□Varicose Veins □Ankle Swelling □Stroke
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☞☞☞ GENERAL CODE
□Fatigue □Allergies □Loss of sleep □Fever □Headaches
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☞☞☞ EENT CODE
□Vision Problems□Dental Problems□Sore Throat□Ear Aches
□Hearing Difficulty□Stuffed Nose
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☞☞☞ GASTRO-INTESTIAN CODE
□Poor/Excessive Appetite □Excessive Thirst □Frequent Nausea
□Vomiting□Diarrhea□Constipation□Hemorrhoids□Liver Problems
□Gall Bladder Problems □Weight Trouble □Abdominal Cramps
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☞☞☞ MALE/FEMALE CODE
□Prostate/Sexual Dysfunction □Menstrual Irregularity □Menstrual Cramping
□Breast Pain/Lumps □Vaginal Pain/Infection
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I hereby authorize my insurance benefits to be paid directly to Unique Care LLC and acknowledge that I am financially responsible for Non-Covered Services. I herby authorize my physician and/or any other providers to release information required to support my claim.
Signed______Date______
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